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General NPI Number Information
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NPI Number | 1205109667
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Entity Type | Organization
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Legal Business Name | GENA RUSSO
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Dates
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Enumeration Date | 02/15/2012
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Last Update Date | 02/15/2012
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Provider Practice Location Address
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Address Line | 2984 S WABASH ST
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City | DENVER
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State | CO
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Zip | 80231-4223
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Country | US
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Telephone | 860-874-7149
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Fax |
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Provider Business Mailing Address
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Address Line | 2984 S WABASH ST
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City | DENVER
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State | CO
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Zip | 80231-4223
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Country | US
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Telephone | 860-874-7149
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Fax |
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Authorized Official
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Title or Position | LICSENSED CLINICAL SOCIAL WORKER
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Name | GENA HOPE RUSSO
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Credential | LCSW
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Telephone | 860-874-7149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 1957
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License Number State | CO
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